tDCS Combined with a Brief Cognitive Intervention to Reduce Perioperative Pain and Opioid Requirements in Veterans

适当地控制疼痛是医疗保健中最重要的领域之一。我们仍然严重依赖阿片类药物 麻醉药品用于急慢性疼痛控制，尽管越来越多的证据表明其风险和缺乏很强的疗效。 在外科人群中，阿片类药物处方很常见，而且通常被认为是良好的做法， 术后阿片类药物处方的数量和持续时间与随后的阿片类药物滥用密切相关， 围手术期阿片类药物的使用与发病率和死亡率的增加有关。全膝关节置换术 全膝关节置换术(TKA)是最常见的骨科手术之一。虽然膝盖疼痛通常是一种抱怨， 在TKA之前，手术本身与持续数天至数周的相当大的术后疼痛有关。 数据表明，在这一人群中，适当的术后疼痛控制是决定 手术结果、康复时间和住院时间。而与将军澳相关的技术 在过去的几年里，手术本身发展迅速，术后疼痛管理技术 几十年来没有实质性的变化，尽管目前采用了疼痛管理 治疗策略方面，患者仍报告有相当大的术后疼痛，并且常常挣扎着完成手术。 理疗方案。需要新的止痛策略，可以与现有的止痛策略一起使用 有可能减少对阿片类止痛的依赖，并减少术后疼痛的策略。 几种新的脑刺激技术，包括经颅直流电刺激(Tdcs)， 开始显示出治疗各种疼痛状况的希望，包括围手术期疼痛。在……里面 最近的一系列研究表明，tdcs可以减少术后阿片类药物的使用 43%，同时降低主观疼痛评级。这项最新的科学工作(以及其他人的工作) 提示用tdcs刺激人类大脑皮层的痛觉调制区域有可能产生 有意义的止痛效果，减少术后阿片类药物的使用，风险或副作用最小。 另一种风险最小、潜在好处也很好的非药物止痛方法是 疼痛认知行为疗法(CBT-P)。CBT-P一贯证明了坚实的经验支持，因为 这是一种治疗慢性疼痛的有效方法，但在围手术期环境中研究较少。尽管如此，还是有一些 小规模研究表明，短暂的认知-行为干预作为一种辅助的后遗症是有希望的。 手术疼痛管理策略，但还需要更多的工作。有趣的是，从我们的数据中积累 研究小组认为，前额叶皮质的TDCs可能增强了认知-行为的镇痛效应 (Cb)对急性疼痛的干预。当与短暂的认知-行为干预相结合时 疼痛，tDCs似乎增强了认知-行为干预的止痛益处，而 提高参与者从中受益的主观能力。看起来tdcs可能能够启动 促进参与止痛认知和行为的大脑区域的神经回路 模式。因此，当在TDC期间向患者传授认知-行为疼痛管理策略时， 与单独干预相比，观察到更多的止痛益处。到目前为止，还没有研究直接 研究了手术后联合应用这些方法的止痛益处。建议数 这项研究将是有史以来第一次(1)确定术后tdcs的独立影响和一个简短的 认知行为干预对TKA术后疼痛、阿片类药物使用和功能的影响(2) 确定将tdcs与短暂的认知-行为干预相结合的效果，以及(3)确定 术后TDC和认知行为干预对疼痛、阿片类药物使用、 全膝关节置换术患者的生活质量和功能。这项创新的、高质量的临床试验有可能 产生可能改变现代手术后疼痛管理范式的发现，以利用 神经科学和行为科学的最新发展。

The proper control of pain is one of the most important areas in health care. We still rely heavily on opioid narcotics for acute and chronic pain control despite growing evidence of their risks and lack of strong efficacy. In surgical populations, where opioid prescribing is common and often believed to be good practice, the amount and duration of post-operative opioid prescriptions are strongly related to subsequent opioid misuse, and perioperative opioid use is associated with increased morbidity and mortality. Total knee arthroplasty (TKA) is one of the most common orthopaedic procedures performed. While knee pain is often a complaint that precedes TKA, the procedure itself is associated with considerable post-operative pain lasting days to weeks. Data suggest that adequate post-operative pain control in this population is an important factor in determining surgical outcomes, recovery time, and hospital length of stay. While the technology associated with the TKA procedure itself has developed rapidly in the past several years, post-operative pain management techniques have not changed substantially in several decades, and despite the currently employed pain-management strategies, patients still report considerable post-operative pain, and often struggle to complete post-operative physical therapy regimens. New analgesic strategies are needed that can be used adjunctively with existing strategies that have the potential to reduce reliance on opioid analgesia, and reduce post-operative pain. Several novel brain stimulation technologies including transcranial direct current stimulation (tDCS) are beginning to demonstrate promise as treatments for a variety of pain conditions including perioperative pain. In a series of recent studies, the PI has shown that tDCS can reduce post-operative opioid use by as much as 43% while simultaneously reducing subjective pain ratings. This recent scientific work (and the work of others) suggests that stimulating pain-modulating areas of the human cortex with tDCS has the potential to yield meaningful analgesic effects and reduce post-operative opioid consumption with minimal risks or side-effects. Another non-pharmacologic approach to pain-management with minimal risks and good potential benefit is cognitive behavioral therapy for pain (CBT-P). CBT-P has consistently demonstrated solid empirical support as an effective treatment for chronic pain, but it is less well-studied in perioperative settings. Nonetheless, a few small studies have demonstrated that brief cognitive-behavioral interventions hold promise as adjunctive post- operative pain management strategies, but more work is needed. Interestingly, accumulating data from our group suggest that tDCS of the prefrontal cortex may augment the analgesic effects of cognitive-behavioral (CB) interventions for acute pain. When combined with a brief cognitive-behavioral intervention for acute pain, tDCS appears to enhance the analgesic benefits of the cognitive-behavioral intervention while improving participants’ subjective capacity to benefit from it. It appears that tDCS may be able to prime neural circuits that facilitate engagement of brain areas involved with pain-reducing cognitions and behavioral patterns. Thus, when cognitive-behavioral pain management strategies are taught to patients during tDCS, more analgesic benefit is observed than with either intervention alone. To date, no studies to date have directly investigated analgesic benefits of combining these approaches in the post-operative arena. The proposed study will be the first ever to (1) determine the independent effects of post-operative tDCS and a brief cognitive-behavioral intervention on post-operative pain, opioid use and functioning following TKA, (2) determine the effects of combining tDCS with a brief cognitive-behavioral intervention, and (3) determine longer-term outcomes of post-operative tDCS and a cognitive-behavioral intervention on pain, opioid use, quality of life, and functioning in TKA patients. This innovative, high-quality clinical trial has the potential to generate findings that could shift the modern paradigm of post-operative pain management to take advantage of recent neuroscience and behavioral-science developments.